Ohio IDR Arbitration For Medical Revenue Recovery

Ohio Surprise Billing Law (SBL)

The Ohio Surprise Billing Law (SBL) became effective on April 1, 2021, and is codified in Ohio Revised Code (ORC) Sections 3902.50 – 3902.54. The law establishes standards for reimbursement and arbitration procedures for out-of-network (OON) services provided under specific conditions, ensuring patient protection against unexpected medical bills.

Key Provisions of the Ohio SBL

1. Reimbursement Standards:
   • For emergency services and inadvertent treatment, reimbursement is determined as the greatest of:
     1. The median in-network rate for the geographic area.
     2. The usual method used by the health plan to pay OON providers, such as UCR (Usual, Customary, and Reasonable) rates.
     3. The applicable Medicare rate.
2. Arbitration Process:
   • If parties cannot reach an agreement within 30 days, either party may initiate arbitration.
3. Arbitration Timelines and Claim Bundling:
   • Arbitration must be initiated within 1 year of the service date.
   • Providers may bundle up to 15 claims involving the same health plan and similar services into a single arbitration process.

Scope of Application

The Ohio SBL governs OON reimbursement for:

• Emergency Services:
  • Provided by nonparticipating providers or facilities.
• Nonemergency Services:
  • Rendered by nonparticipating providers at in-network facilities when the patient did not knowingly consent to receive care from an OON provider.

State and Federal Coordination

1. Specified State Laws:
   • ORC Sections 3902.50 – 3902.54 apply to OON rate determinations for emergency and nonemergency services provided by nonparticipating providers at in-network facilities.
2. Federal Dispute Resolution for Excluded Services:
   • The federal independent dispute resolution (IDR) process under Section 2799A-2(b) of the Public Health Service (PHS) Act and 45 CFR 149.520 applies to:
     • Services provided by nonparticipating air ambulance providers.
     • Any cases not governed by Ohio’s SBL.
3. State Enforcement:
   • The Ohio Department of Insurance enforces arbitration outcomes for state-governed cases and oversees the implementation of the federal IDR process for federally governed cases.

CMS Clarifications

In a letter from CMS to the Governor of Ohio (February 17, 2021), CMS provided the following details:

1. No All-Payer Model Agreement:
   • Ohio does not have an All-Payer Model Agreement to determine OON rates.
2. Specified State Laws:
   • ORC 3902.50 – 3902.54 apply to OON reimbursement determinations for emergency and certain nonemergency services.
3. Federal Process for Air Ambulance Claims:
   • The federal IDR process applies to claims involving nonparticipating air ambulance providers and other cases excluded from Ohio’s SBL.

Conclusion

The Ohio SBL provides robust protection for patients against surprise medical bills while ensuring fair reimbursement for OON services. It defines clear reimbursement standards, offers a streamlined arbitration process, and integrates with federal regulations to address services outside the state law’s scope.